King LTS-D, ResQPod, Waveform Capnography, EZ-IO

If you have experience using the above captioned devices for cardiac arrest I have a couple of questions.

1.) Do you use a gastric tube in combination with the King LTS-D? If so, when and how do you insert it? Do you insert the tube up to the distal tip of the King prior to insertion of the King or just insert the King first and the gastric tube later? Do you attach it to suction right away or only if you suspect a problem? How long do you apply suction? Until no gastric contents are coming up the tube? Does it work well or does it get clogged?

2.) When you identify ROSC (thanks to waveform capnography) and the ETCO2 is above 45 do you hyperventilate the patient to bring down the ETCO2 below 45 or continue to ventilate the patient every 6-8 seconds (or when the light on the ResQPOD blinks)? Or would you expect the ETCO2 to come down below 45 on its own provided that ROSC persists.

3.) Do you bother with attempting IV access or go strait to IO or do you evaluate the patient's peripheral access and decide on a case-to-case basis?

4.) I'd like to know how many people are dispatched to a cardiac arrest in your system, particularly if your system is doing well with survival to hospital discharge. Include first responders and supervisors.

One of our emergency physicians has raised concerns about the effectiveness of the King and is quite adamant that it should be considered a rescue airway ONLY and never a primary airway, even for cardiac arrest. He feels that it does not adequately ventilate patients in comparison to tracheal intubation.

This is based on a case where EMS lost ROSC in the field several times (but identified it immediately because there was a significant change in ETCO2), chest compressions were continued, the ResQPOD was replaced, the patient was shocked, and ROSC was restored several times en route.

Apparently the patient's ABGs showed more CO2 than some of the ED physicians were hoping to see. The patient was intubated with a tracheal tube in the emergency department and apparently that rectified the problem.

I personally find it to be ironic that we are hearing complaints now that patients are surviving to hospital admission. I feel like patients could arrive pulseless with a tube in the right hole and no questions would be asked, but who knows.

We did have a problem with gastric contents inside the King and had to remove it, suction the patient, and replace the King (which is why I'm asking about the gastric tube).

My concern is that we will lose support for the King LTS-D before it's had a legitimate chance to work in the field. I don't think we ought to dictate to paramedics how they capture the airway because I think it should be based on a variety of factors including the patient's airway anatomy (predicted difficulty of intubation), circumstances on scene, experience level of the paramedic, and whether or not chest compressions will need to be interrupted (and how many times) for laryngoscopy.

So let's hear it! I'll be interested to hear what you guys have to say.

Replies to This Discussion

Agreed! So how much more evidence do we need that tracheal intubation is a high risk / low frequency invasive procedure that takes a lot of experience to master? I don't see too many EMS systems putting the time, money, and effort into measuring, improving, and maintaining proficiency at laryngoscopy. The King LTS-D is an attempt to "rectify a problem". The idea that the only definitive airway is a tracheal tube ignores all of the problems inherent in how the tube gets placed. ("What's the big deal? Just drop the tube. It just takes a second! Paramedics are the airway specialists!") Sounds great. But is it true?

Absolutely! I'm aware of cardiocerebral resuscitation. Just wanted clarification on what he was advocating.

Tom

dr-exmedic said:

Tom Bouthillet said:

I would place a tube of some kind so that asynchonous ventilations can be administered (without interrupting chest compressions).

Or are you suggesting withholding ventilations altogether in the first several minutes?

If you look at the guidelines for CCR (cardio-cerebral resuscitation, which is basically a better version of CPR that the AHA has yet to endorse fully--a total failure of the ECC committee IMHO), they advocate passive O2 insufflation using NRM and OPA for the first 4 cycles of CPR (each 200 uninterrupted compressions) if the pt is in a shockable rhythm.

Tom, my approach to the IO is similar to my approach to intubation. I take a quick look at their AC's and jump to the IO if I don't see anything big enough for an 18. For the airway, I take a quick look with the laryngoscope during chest compressions and use the Combitube if I don't see anything. I've recently had success intubating with the bougie without stopping chest compressions.

I don't have any experience with the King. One possible solution to the situation you describe would be to use a bougie to intubate through the port in the king. I've done this on mannequins but don't know how effective it is in real life.

I imagine suctioning gastric contents with any airway device in place would decrease intrathoracic pressure and improve CPR. I also believe that unless you have CCR protocols, an advanced airway should be placed as soon as possible, during chest compressions, so that they don't need to be interrupted during ventilation. The goal of all these treatments should be to improve the effectiveness of chest compressions.

In the city where I primarily work, a BLS ambulance, a BLS fire truck, and two QRV paramedics respond to cardiac arrests. Outside city limits in the county, the minimum response is a BLS ambulance with two people and two paramedics. The volunteer fire department is toned out as well. Sometimes 20 people show up and sometimes none do.

Actually, I am quite comfortable with my intubation skills. I have been successfully intubating patients for over 25 years and have taught airway management for 15+ years. I have regular airway training and skill validations using SimMan and get to the OR as often as is possible.

I have found that I can insert a King Airway much faster than intubating the patient and without interrupting compressions. This is not laziness on my part but rather a conclusion that I have drawn from my experience that has been backed up by medical directors I have worked under in 2 different states and by the latest AHA guidelines which have deemphasized the use of advanced airways early in the resuscitation preferring to focus on quality CPR with the proper rate and depth.

When calling some out it is probably best to quote them properly. If I get ROSC I will *CONSIDER* changing out the King for a ET tube. If I am getting adequate tidal volume and the patients ETCO2 is acceptable I will continue to utilize the King airway.

I resent the implication that my choice of airway is lazy and that I pay no attention to the airway. I pay significant attention to the airway but choose to keep airway management in cardiac arrest in perspective. Interruptions in compressions need to be kept to a minimum and if I can eliminate or further minimize interruptions by using a King and still provide adequate tidal volume I think I am providing better patient care.

Up until a few years ago I thought like you did, that I was not providing the best care if I did not endotracheally intubate each and every patient. Then I started reading the science and seeing results that showed Kings and Combitubes could be just as appropriate for airway management in the field in cardiac arrest. While I think we both agree that endotracheal intubation is a very important skill in the paramedic scope of practice I think that we will have to continue to disagree that endotracheal intubation is the ONLY appropriate way that we can successfully manage the airway in cardiac arrest.

--Harry

Matt King said:

Harry with all due respect this is concerning "I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered." Who taught you that this is acceptable? What standard airway algorythm or protocol advocates this? It takes me < 2 minutes to set up for intubation and perform the procedure appropriately and safely for the PT. And I by no means am an airway Guru... It barely takes longer to intubate a PT in regards to placing a King tube. You still have to take it out of the package, lube it up generously, inflate the cuff to make sure it hasn't blown and then insert. Yes, less time than a traditional intubation method, but not much. And then you stated that if you get an ROSC that you will then take it out and place an ET tube. You do realize that the King tube and Combi-tube do cause trauma almost every time leading to bleeding, swelling and decreasing your chances of a successful traditional direct laryngoscopy right? So why not just take your time, since you have time(they're dead), and do what's right for the PT. Plus, cardiac arrests are considered crash airways which lends to no gag reflex and to very very little muscle tone. It's like the PT is paralized and you didn't have to push an NMBA and accept the responsibility of doing it yourself. These are generally considered the easiest and best intubating conditions. Do you not feel confident in your intubating skills or what? Not trying to call you out, but this sounds lazy and rushed. Cardiac arrests are no time to be rushed, just methodical and steady. I'm sorry that your are the recipient of my soap box, but seeing this mentality from you and other providers on here is concerning and frustrating. I have been in EMS long enough and know that this was never taught to be acceptable and is not currently the standard of care in airway maintainence. If this is something because you don't get many chances to intubate or your EMS service provides little to no CEs(like Sim man practice intubations, OR rotations, or Airway seminars) then I understand your thinking. But if not then I believe you have no excuse providing this type of care. If it's the first option then your need a better, more dedicated medical director. Airway is the cornerstone of our existance and yet we pay very little attention to it. Again not a paragod or Guru. Just my .02 worth...

Respectfully,

Matt King

Harry Mueller said:

Hi Tom,

My view on this topic is:

1. I have had very good results using the King. I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered. I will put the gastric tube in when time permits unless I think I have a large amount of air in the gut in which case I put it in and attach suction until I stop getting gastric contents returning. I have and not problems with gastric content leakage in the few dozen times I have used it. If I end up with ROSC or not terminating the resuscitation in the field I will consider changing out the King for an ET tube but don't do that routinely, there would have to be a good reason. My feeling is that if I am getting adequate air movement with good ETCO2 waveform and have a patent airway I'm going to stick with what is working unless there is a good reason to try something else.

2. I tend to always ventilate the patient using the ETCO2 after ROSC so I can be sure I am not hypo/hyperventilating them. The blinky light is fine if you have no other way of monitoring the patients actual respiratory status but for me capnography is king. Eventually the ETCO2 will probably come down below 45 on its own but it will take longer than if you are titrating ventilation with the ETCO2.

3. Now that we have a little time between the time we start CPR and the time that we need to give meds I will generally allow 15-20 secs to search for an IV site (provided I have people to spare) but is there is no obvious site or if I am short personnel I'll go straight to IO. This is probably my own dinosaur bias from the days when IO was limited to last ditch vascular access.

4. Generally we will respond with a Intermediate level ambulance (2-3 people), a non-transport solo paramedic, and an engine company (3 people) which may be staffed with a paramedic but usually is at the Intermediate level. For 2010 we had a 30% survival to discharge rate but that was unusually high since most of our cardiac arrests occurred in the core of the community and very few in the more rural areas. Usually we average about 8% primarily, I think, due to longer time between 911 activation and arrival of personnel in the rural portions of our district.

By and large I have not found many circumstances when I was not able to adequately ventilate with a King airway in place. I have seen patients brought into the ED with higher PCO2 levels on the ABG but my experience has been that these ROSC patients were not having their ventilation rate determined by the ETCO2 levels. This may not be true in the case your physician is referring to but it is one possibility.

As much as I enjoy intubating I am rapidly becoming a firm supporter of using some of these alternative airways provided that adequate tidal volume can be achieved. Having discussed the topic of not intubating every cardiac arrest with an ED physician a few weeks ago I found that some physicians just have a bias against these alternative airways and until there is enough evidence to satisfy them that they are just as effective for most patients they would still prefer to see patients intubated since intubation is still the "Gold Standard" in their eyes.

Harry we can go around in circles forever on this, but instead I'll agree to disagree.

Respectfully,

Matt

Harry Mueller said:

Matt,

Actually, I am quite comfortable with my intubation skills. I have been successfully intubating patients for over 25 years and have taught airway management for 15+ years. I have regular airway training and skill validations using SimMan and get to the OR as often as is possible.

I have found that I can insert a King Airway much faster than intubating the patient and without interrupting compressions. This is not laziness on my part but rather a conclusion that I have drawn from my experience that has been backed up by medical directors I have worked under in 2 different states and by the latest AHA guidelines which have deemphasized the use of advanced airways early in the resuscitation preferring to focus on quality CPR with the proper rate and depth.

When calling some out it is probably best to quote them properly. If I get ROSC I will *CONSIDER* changing out the King for a ET tube. If I am getting adequate tidal volume and the patients ETCO2 is acceptable I will continue to utilize the King airway.

I resent the implication that my choice of airway is lazy and that I pay no attention to the airway. I pay significant attention to the airway but choose to keep airway management in cardiac arrest in perspective. Interruptions in compressions need to be kept to a minimum and if I can eliminate or further minimize interruptions by using a King and still provide adequate tidal volume I think I am providing better patient care.

Up until a few years ago I thought like you did, that I was not providing the best care if I did not endotracheally intubate each and every patient. Then I started reading the science and seeing results that showed Kings and Combitubes could be just as appropriate for airway management in the field in cardiac arrest. While I think we both agree that endotracheal intubation is a very important skill in the paramedic scope of practice I think that we will have to continue to disagree that endotracheal intubation is the ONLY appropriate way that we can successfully manage the airway in cardiac arrest.

--Harry

Matt King said:

Harry with all due respect this is concerning "I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered." Who taught you that this is acceptable? What standard airway algorythm or protocol advocates this? It takes me < 2 minutes to set up for intubation and perform the procedure appropriately and safely for the PT. And I by no means am an airway Guru... It barely takes longer to intubate a PT in regards to placing a King tube. You still have to take it out of the package, lube it up generously, inflate the cuff to make sure it hasn't blown and then insert. Yes, less time than a traditional intubation method, but not much. And then you stated that if you get an ROSC that you will then take it out and place an ET tube. You do realize that the King tube and Combi-tube do cause trauma almost every time leading to bleeding, swelling and decreasing your chances of a successful traditional direct laryngoscopy right? So why not just take your time, since you have time(they're dead), and do what's right for the PT. Plus, cardiac arrests are considered crash airways which lends to no gag reflex and to very very little muscle tone. It's like the PT is paralized and you didn't have to push an NMBA and accept the responsibility of doing it yourself. These are generally considered the easiest and best intubating conditions. Do you not feel confident in your intubating skills or what? Not trying to call you out, but this sounds lazy and rushed. Cardiac arrests are no time to be rushed, just methodical and steady. I'm sorry that your are the recipient of my soap box, but seeing this mentality from you and other providers on here is concerning and frustrating. I have been in EMS long enough and know that this was never taught to be acceptable and is not currently the standard of care in airway maintainence. If this is something because you don't get many chances to intubate or your EMS service provides little to no CEs(like Sim man practice intubations, OR rotations, or Airway seminars) then I understand your thinking. But if not then I believe you have no excuse providing this type of care. If it's the first option then your need a better, more dedicated medical director. Airway is the cornerstone of our existance and yet we pay very little attention to it. Again not a paragod or Guru. Just my .02 worth...

Respectfully,

Matt King

Harry Mueller said:

Hi Tom,

My view on this topic is:

1. I have had very good results using the King. I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered. I will put the gastric tube in when time permits unless I think I have a large amount of air in the gut in which case I put it in and attach suction until I stop getting gastric contents returning. I have and not problems with gastric content leakage in the few dozen times I have used it. If I end up with ROSC or not terminating the resuscitation in the field I will consider changing out the King for an ET tube but don't do that routinely, there would have to be a good reason. My feeling is that if I am getting adequate air movement with good ETCO2 waveform and have a patent airway I'm going to stick with what is working unless there is a good reason to try something else.

2. I tend to always ventilate the patient using the ETCO2 after ROSC so I can be sure I am not hypo/hyperventilating them. The blinky light is fine if you have no other way of monitoring the patients actual respiratory status but for me capnography is king. Eventually the ETCO2 will probably come down below 45 on its own but it will take longer than if you are titrating ventilation with the ETCO2.

3. Now that we have a little time between the time we start CPR and the time that we need to give meds I will generally allow 15-20 secs to search for an IV site (provided I have people to spare) but is there is no obvious site or if I am short personnel I'll go straight to IO. This is probably my own dinosaur bias from the days when IO was limited to last ditch vascular access.

4. Generally we will respond with a Intermediate level ambulance (2-3 people), a non-transport solo paramedic, and an engine company (3 people) which may be staffed with a paramedic but usually is at the Intermediate level. For 2010 we had a 30% survival to discharge rate but that was unusually high since most of our cardiac arrests occurred in the core of the community and very few in the more rural areas. Usually we average about 8% primarily, I think, due to longer time between 911 activation and arrival of personnel in the rural portions of our district.

By and large I have not found many circumstances when I was not able to adequately ventilate with a King airway in place. I have seen patients brought into the ED with higher PCO2 levels on the ABG but my experience has been that these ROSC patients were not having their ventilation rate determined by the ETCO2 levels. This may not be true in the case your physician is referring to but it is one possibility.

As much as I enjoy intubating I am rapidly becoming a firm supporter of using some of these alternative airways provided that adequate tidal volume can be achieved. Having discussed the topic of not intubating every cardiac arrest with an ED physician a few weeks ago I found that some physicians just have a bias against these alternative airways and until there is enough evidence to satisfy them that they are just as effective for most patients they would still prefer to see patients intubated since intubation is still the "Gold Standard" in their eyes.

I can tell you that in the Army the Combi tube and King Lt were taken out of the Tactical Combat Casualty Care guidelines. A study was conducted on the effectivness of these rescue devices and it showed that trauma patients that could accept this type of device had a survival rate of zero. The king lt is the airway of choice for medical patients requiring an airway by a Medic that is not assigned to a Special Operation Unit . The combi Tube was removed from the supply channel. I did a low budget study in 2004 I trained 460 students on how to use the King Lt and another 460 on how to use the Combi tube. This was done prior to their medical training and in week 9 I tested them and the success rate of the King was higher that the Combi. Less moving parts was the reason for the success these were Army Medic/EMT-B canidates. I will look for the study and see if I can email you those. I have used both airways and I think that they are the same with the difference that one requires more trainining.